风湿性心脏病瓣膜置换术后心房颤动的导管消融病例总结

Analysis of atrial fibrillation ablation in patients with rheumatic heart disease after valvula surgery

目的评价风湿性心脏病瓣膜置换术后心房颤动(房颤)消融的效果和安全性。方法入选2008年至2013年在广东省人民医院心内科接受房颤导管消融治疗的风湿性心脏病瓣膜置换术患者,分析其临床特征、消融策略及消融成功率。结果共纳入23例患者,男8例,女15例,平均年龄(51.0±9.2)岁。单纯二尖瓣置换术患者13例(56.5%),二尖瓣、主动脉瓣双瓣置换术10例(43.5%),其中5例同时进行三尖瓣置换或整形术。外科术后阵发性房颤患者14例(60.9%),非阵发性房颤9例(39.1%);这些患者在外科术前心律情况为9例窦性心律,4例阵发性房颤,10例非阵发性房颤。导管消融距离外科手术时间为(6.9±5.8)年,外科术后发生房颤病程(3.1±3.2)年,左、右心房内径分别为(44.1±5.9)mm、(48.1±9.0)mm,左心室射血分数64.0%±8.3%。平均消融手术时间(156.8±46.6)min,X线曝光时间(27.3±11.2)min。随访(29.7±21.2)个月,其中4例(17.4%)患者接受再次消融术;14例(60.9%)维持窦性心律(6例服用胺碘酮),1例死亡,2例失访,6例复发(包括2例持续性房颤,1例阵发性房颤,2例偶发性心房扑动,1例阵发性房性心动过速)。结论风湿性心脏病瓣膜置换术后房颤导管消融有效、安全,步进式导管消融策略可能较为合适。

Objective To observe efifcacy and safety of catheter ablation for atrial ifbrillation （AF） occurring after surgical valve replacement in patients with rheumatic heart disease （RHD）. Methods A total of 23 RHD patients with atrial ifbrillation after surgical valve replacement were enrolled in this study from 2008 to 2013. The clinical characteristics, ablation strategies and successful rate were investigated. Results All the cases included 8 males and 15 females （age, 51.0 ＆#177; 9.2 years）. Valves replaced were isolated mitral valves （13/23, 56.5%） and multiple valves （10/23, 43.5%）. Postoperative AF after cardiac surgery was paroxysmal in 14 patients （60.9%） and nonparoxysmal in 9 cases. Nine patients （39.1%） was in sinus rhythm before cardiac surgery, 4 in paroxysmal AF and 10 in non-paroxysmal AF. The mean interval between the catheter ablation AF and the surgical intervention was （6.9＆#177;5.8） years. The postoperative AF duration was （3.1＆#177;3.2） years, left and right atrial diameters were （44.1＆#177;5.9） mm and （48.1＆#177;9.0） mm＆amp;nbsp;respectively, left ventricular ejection fraction was 64.0%＆#177;8.3%, the mean ablation procedure duration was （156.8＆#177;46.6） min, and lfuoroscopy exposure averaged （27.3＆#177;11.2） min. Standard pulmonary vein isolation was performed in all cases by using ipsilateral circumferential ablation technique. Additional ablation, including complex fractionated atrial electrograms, mitral and tricuspid isthmus, and left atrial roof, was applied in most of the cases. After a mean follow-up of （29.7＆#177;21.2） months （median, 24 months）, 60.9%of the patients remained free of AF, 1 died, and 2 lost to follow-up. Conclusions Catheter ablation for AF is effective and safe in patients with RHD after surgical valve replacement. Stepwise ablation strategy may be better for these patients.